ATI RN Maternal Newborn Proctored 2

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?

A. Painless red vaginal bleeding

B. Increasing abdominal pain with a nonrelaxed uterus

C. Abdominal pain with scant red vaginal bleeding

D. Intermittent abdominal pain following passage of bloody mucus

A. Painless red vaginal bleeding

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

A. Document the findings and continue to monitor the client.

B. Notify the client‟s provider.

C. Increase the frequency of fundal massage.

D. Encourage the client to empty her bladder.

A. Document the findings and continue to monitor the client.

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

A. Administer vitamin K.

B. Dry the skin.

C. Administer eye prophylaxis.

D. Place an identification bracelet.

B. Dry the skin.

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

A. "It's a minor inconvenience, which you should ignore."

B. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone."

C. "There is no way to predict how long it will last in each individual client."

D. "It occurs during the first trimester and near the end of the pregnancy."

D. "It occurs during the first trimester and near the end of the pregnancy."

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization?

A. Shortly after giving birth

B. In the third trimester

C. Immediately

D. During her next attempt to get pregnant

A. Shortly after giving birth

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

A. Clear the respiratory tract.

B. Dry the infant off and cover the head.

C. Stimulate the infant to cry.

D. Cut the umbilical cord.

A. Clear the respiratory tract.

A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

A. "What part of the exam makes you most nervous?"

B. "Don't worry, I will be with you during the exam."

C. "All you need to do is relax."

D. "A pelvic exam is required if you want birth control pills."

A. "What part of the exam makes you most nervous?"

A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

A. Two veins and one artery

B. One artery and one vein

C. Two arteries and one vein

D. Two arteries and two veins

C. Two arteries and one vein

A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable?

A. A male condom

B. An intrauterine device (IUD)

C. An oral contraceptive

D. A diaphragm with spermicide.

B. An intrauterine device (IUD)

Anurseiscaringforanantepartumclientwhoselaboratoryfindingsindicateanegativerubellatiter.Whichofthe following is the correct interpretation of this data?

A. The client is not experiencing a rubella infection at this time.

B. The client is immune to the rubella virus.

C. The client requires a rubella vaccination at this time.

D. The client requires a rubella immunization following delivery.

D. The client requires a rubella immunization following delivery.

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action?

A. Insert an indwelling urinary catheter.

B. Initiate IV access.

C. Witness the signature for informed consent for surgery.

D. Prepare the abdominal and perineal areas.

B. Initiate IV access.

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

A. Rapid decline in human chorionic gonadotropin (hCG) levels

B. Profuse, clear vaginal discharge

D. Excessive uterine enlargement

D. Excessive uterine enlargement

A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse?

A. "I will call your primary care provider to report your concerns."

B. "I will take your baby to the nursery for further examination."

C. "This occurs because newborns lack muscle control to regulate eye movement."

D. "This is a concern, but strabismus is easily treated with patching."

C. "This occurs because newborns lack muscle control to regulate eye movement."

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?

A. Immediately report the situation to the client's provider and prepare the client for induction of labor.

B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring.

C. Offer the client a snack of orange juice and crackers.

D. Turn the client onto her left side.

C. Offer the client a snack of orange juice and crackers.

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?

A. Notify the provider of the findings.

B. Position the client with one hip elevated.

C. Ask the client if she needs pain medication.

D. Have the client void.

B. Position the client with one hip elevated.

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

A. Rupture of the membranes

B. Changes in the cervix

C. Station of the presenting part

D. Pattern of contractions

B. Changes in the cervix

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Whichof the following is the priority nursing assessment for this client?

A. Temperature

B. Fetal heart rate (FHR)

C. Bowel sounds

D. Respiratory rate

D. Respiratory rate

A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn‟s plan of care?

A. Observe for meconium in respiratory secretions.

B. Monitor for hyperglycemia.

C. Identify manifestations of anemia.

D. Monitor for hyperthermia.

A. Observe for meconium in respiratory secretions.

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

A. Limit alcohol consumption.

B. Increase intake of iron-rich foods.

C. Consume foods fortified with folic acid.

D. Avoid foods containing aspartame.

C. Consume foods fortified with folic acid.

A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?

A. Vaginal intercourse can be resumed after 2 weeks.

B. Products of conception will be present in vaginal bleeding.

C. Increased intake of zinc-rich foods is recommended.

D. Aspirin may be taken for cramps.

A. Vaginal intercourse can be resumed after 2 weeks.

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

A. 1+ pitting sacral edema

B. 3+ protein in the urine

C. Blood pressure 148/98 mm Hg

D. Deep tendon reflexes of +1

D. Deep tendon reflexes of +1

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)

A. Cracked, peeling skin

B. Positive Moro reflex

C. Short, soft fingernails

D. Abundant lanugo

E. Vernix in the folds and creases

A. Cracked, peeling skin

B. Positive Moro reflex

A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?

A. "Exercising during pregnancy is not recommended."

B. "Daily jogging for up to 30 minutes is fine throughout the pregnancy."

C. "Activities that raise the body temperature, such as saunas and hot tubs, are safe until the third trimester."

D. "It is recommended that pregnant clients limit their exercise routine to stretching activities on a mat several times a week."

B. "Daily jogging for up to 30 minutes is fine throughout the pregnancy."

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

A. Cover the cord with a sterile, moist saline dressing.

B. Prepare the client for an immediate birth.

C. Place the client in knee-chest position.

D. Insert a gloved hand into the vagina to relieve pressure on the cord.

D. Insert a gloved hand into the vagina to relieve pressure on the cord.

A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse?

A. "Ambivalent feelings are quite common for women early in pregnancy."

B. "Perhaps you should see a counselor to discuss these feelings further."

C. "Have you spoken to your mother about these feelings?"

D. "Don't worry. You will be fine once the baby is born."

A. "Ambivalent feelings are quite common for women early in pregnancy."

A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?

A. Headaches

B. Nervousness

C. Tremors

D. Dyspnea

D. Dyspnea

A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapyto which of the following clients?

A. A client who is experiencing fetal death at 32 weeks of gestation

B. A client who is experiencing preterm labor at 26 weeks of gestation

C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation

D. A client who has a post-term pregnancy at 42 weeks of gestation

B. A client who is experiencing preterm labor at 26 weeks of gestation

A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?

A. Fundus firm to palpation

B. Increase in blood pressure

C. Increase in lochia

D. Report of absent breast pain

A. Fundus firm to palpation

A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D) immunoglobulin. Which of the following should be included in the teaching?

A. It prevents the formation of Rh antibodies in mothers who are Rh negative.

B. It destroys Rh antibodies in mothers who are Rh negative.

C. It destroys Rh antibodies in newborns who are Rh positive.

D. It prevents the formation of Rh antibodies in newborns who are Rh positive.

A. It prevents the formation of Rh antibodies in mothers who are Rh negative.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following?

A. Fetal lung maturity

B. Location of the placenta

C. Viability of the fetus

D. The biparietal diameter

B. Location of the placenta

A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?

A. "You might want to offer water supplements between feedings."

B. "It is due to the newborn‟s loss of the influence of the maternal hormones."

C. "This might be related to your baby having 3 stools a day."

D. "The cause might be too short or infrequent feedings."

D. "The cause might be too short or infrequent feedings."

A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?

A. "The primary consideration is what type of incision was performed this time."

B. "There are so many variables that you'll have to ask your obstetrician."

C. "It's too soon for you to be worrying about this now."

D. "A repeat cesarean birth is safer for both you and your baby."

A. "The primary consideration is what type of incision was performed this time."

A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

A. "This will occur during the last trimester of pregnancy."

B. "This will happen by the end of the first trimester of pregnancy."

C. "This will occur between the fourth and fifth months of pregnancy."

D. "This will happen once the uterus begins to rise out of the pelvis."

C. "This will occur between the fourth and fifth months of pregnancy."

A nurse is instructing a female client about how to check basal temperature in order to determine if the client is ovulating. The nurse should instruct the client to check her temperature at which of the following times?

A. Every morning before arising

B. On days 13 to 17 of her menstrual cycle

C. 1 hour following intercourse

D. Before going to bed every night

A. Every morning before arising

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

A. Discontinue the medication infusion.

B. Prepare for an emergency cesarean birth.

C. Assess maternal blood glucose.

D. Place the client in Trendelenburg position.

A. Discontinue the medication infusion.

A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer?

A. "You must be feeling scared and powerless."

B. "Everyone worries about her baby when she‟s in labor."

C. "Your pregnancy is advanced so your baby should be fine."

D. "We have a neonatal unit here that‟s equipped to handle emergencies."

A. "You must be feeling scared and powerless."

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

A. Uteroplacental insufficiency

B. Maternal bradycardia

C. Umbilical cord compression

D. Fetal head compression

A. Uteroplacental insufficiency

A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection, and will need intravenous antibiotic therapy. The client tells the nurse, "My parents think I am a virgin. I don't think I can tell them I have this kind of an infection." Which of the following responses should the nurse make?

A. "Give your parents a chance; they'll understand."

B. "If you want me to, I can tell your parents for you."

C. "You seem scared to talk to your parents."

D. "Your parents will have to be told why you are being admitted."

C. "You seem scared to talk to your parents."

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the following statements should the nurse include in the teaching?

A. "This medication promotes softening of the cervix."

B. "This medication is used to treat preeclampsia."

C. "It causes relaxation of the uterine muscles."

D. "It is used to treat genital herpes simplex virus."

A. "This medication promotes softening of the cervix."

A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeksof gestation. The nurse provides which of the following explanations about this test to the client?

A. This test assesses fetal lung maturity.

B. It assesses various markers of fetal well-being.

C. This test identifies an Rh incompatibility between the mother and fetus.

D. It is a screening test for spinal defects in the fetus.

D. It is a screening test for spinal defects in the fetus.

A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse

should instruct the client to call the clinic if she experiences which of the following manifestations?

A. Leukorrhea

B. Urinaryfrequency

C. Nausea and vomiting

D. Facial edema

D. Facial edema

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

A. Severe nausea and vomiting

B. Large amount of vaginal bleeding

C. Unilateral, cramp-like abdominal pain

D. Uterine enlargement greater than expected for gestational age

C. Unilateral, cramp-like abdominal pain

A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

A. Consume 40 to 50 g of protein daily.

B. Avoid salting of foods during cooking.

C. Drink 48 to 64 ounces of water daily.

D. Limit intake of whole grains, raw fruits, and vegetables.

C. Drink 48 to 64 ounces of water daily.

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

A. Maintain the integrity of the sac.

B. Promote maternal-infant bonding.

C. Educate the parents about the defect.

D. Provide age-appropriate stimulation.

A. Maintain the integrity of the sac.

A nurse in a college health clinic is speaking to a group of adolescents about toxic shock syndrome (TSS). Which of the following should the nurse include in the teaching as increasing the risk for contracting TSS?

A. High-absorbency tampons

B. Mosquito bites

C. Travel to foreign countries

D. Multiple sexual partners

A. High-absorbency tampons

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD. For example, July 27 is 0727)

A. 0504

A. 0504

A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make?

A. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding."

B. "Your baby should wet 6 to 8 diapers per day."

C. "Your baby should burp after each feeding."

D. "Your baby should sleep at least 6 hours between feedings."

B. "Your baby should wet 6 to 8 diapers per day."

A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

A. "You need to take pain medications so you are more comfortable."

B. "We can time your pain medication so that you have an hour or two before the next feeding."

C. "All medications are found in breast milk to some extent."

D. "You have the option of not taking pain medication if you are concerned."

B. "We can time your pain medication so that you have an hour or two before the next feeding."

A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide?

A. "This infection is treated with one dose of azithromycin."

B. "If your sexual partner has no symptoms, no medication is needed."

C. "You have to avoid sexual relations for 3 days."

D. "You need to return in 6 months for retesting."

A. "This infection is treated with one dose of azithromycin."

A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent neural tube defects in the fetus?

A. Calcium

B. Iron

C. Vitamin C

D. Folic acid

D. Folic acid

A nurse in a prenatal clinic is completing a skin assessment of a client who is in the second trimester. Which of the following findings should the nurse expect? (Select all that apply.)

A. Eczema

B. Psoriasis

C. Linea nigra

D. Chloasma

E. Striae gravidarum

C. Linea nigra

D. Chloasma

E. Striae gravidarum

A nurse is reviewing the health history of a client who has a new prescription for a combined oral contraceptive (COC). The nurse recognizes that which of the following client medications can interfere with the effectiveness of the COC?

A. Antihypertensives

B. Anticonvulsants

C. Antioxidants

D. Antiemetics

B. Anticonvulsants

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply.)

A. History of migraines

B. Nulliparous

C. Twin gestations

D. History of gestational hypertension

E. Oligohydramnios

A. History of migraines

B. Nulliparous

C. Twin gestations

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?

A. "The newborn might be actively shedding the virus."

B. "The newborn is at risk for developing a TORCH infection."

C. "The child might develop encephalitis, a complication of rubella."

D. "Exposure to rubella will suppress the newborn‟s immune response."

A. "The newborn might be actively shedding the virus."

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother‟s room. Which of the following is an appropriate response by the nurse?

A. "You may carry your grandchild to the room."

B. "You can push the baby to the room in a wheeled bassinet."

C. "Have the mother call and I will take the baby to the room."

D. "If you show me your photo identification, you can take the infant."

C. "Have the mother call and I will take the baby to the room."

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

A. The fetal head is in the left occiput posterior position.

B. The largest fetal diameter has passed through the pelvic outlet

C. The posterior fontanel is palpable.

D. The lowermost portion of the fetus is at the level of the ischial spines.

D. The lowermost portion of the fetus is at the level of the ischial spines.

57.A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse‟s priority?

A. Respiratory distress

B. Hypothermia

C. Accidental lacerations

Acrocyanosis

A. Respiratory distress

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?

A. "You are so young. Are you ready for the responsibilities of a sexual relationship?"

B. "Because of your age, I think that a barrier method would be the best choice."

C. "Before I can help you, I need to know more about your sexual activity."

D. "A provider can help you with that after a physical examination."

C. "Before I can help you, I need to know more about your sexual activity."

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

A. Copious vernix

B. Scant scalp hair

C. Increased subcutaneous fat

D. Dry, cracked skin

D. Dry, cracked skin

A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching?

A. "You will need to increase your calcium intake during breast feeding."

B. "Prenatal vitamins will meet your need for increased vitamin D during pregnancy."

C. "Vitamin E requirements decline during pregnancy due to the increase in body fat."

D. "You will need to double your intake of iron during pregnancy."

D. "You will need to double your intake of iron during pregnancy."

A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?

A. "Preterm newborns have a smaller body surface area than normal newborns."

B. "The added brown fat layer in a preterm newborn reduces his ability to generate heat."

C. "Preterm newborns lack adequate temperature control mechanisms."

D. "The heat in the incubator rapidly dries the sweat of preterm newborns."

C. "Preterm newborns lack adequate temperature control mechanisms."

A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client‟s newborn at risk for which of the following complications?

A. Hearing loss

B. Intrauterine growth restriction

C. Type 1 diabetes mellitus

D. Congenital heart defects

B. Intrauterine growth restriction

A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as an indication of inhibition of parental attachment?

A. "He‟s got my husband‟s nose, that‟s for sure."

B. "I don‟t need a baby bath demonstration. I know how to do it."

C. "I wish he had more hair. I will keep a hat on his head until he grows some."

D. "Do you think you could keep him in the nursery for the next feeding so I can get some sleep?"

C. "I wish he had more hair. I will keep a hat on his head until he grows some."

A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?

A. "It would be best if you gained about 11 to 20 pounds."

B. "The recommendation for you is about 15 to 25 pounds."

C. "A gain of about 25 to 35 pounds is recommended for you."

D. "A gain of about 1 pound per week is the best pattern for you."

B. "The recommendation for you is about 15 to 25 pounds."

A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundusis three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?

A. The client is exhibiting early indications of mastitis.

B. Additional interventions are not indicated at this time.

C. Application of a heating pad to the breasts is indicated.

D. The client should be advised to remove her nursing bra.

B. Additional interventions are not indicated at this time.

A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn‟s head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? to

A. "You should go ahead and push to assist the delivery."

B. "You should try to pant as the delivery proceeds."

C. "You should try to perform slow-paced breathing."

D. "You should take a deep, cleansing breath and breathe naturally."

B. "You should try to pant as the delivery proceeds."

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

A. "I'll let my baby drain one breast at each feeding."

B. "I‟ll try drinking an herbal tea to reduce the engorgement."

C. "I‟ll apply cold compresses 20 minutes before each feeding."

D. "I‟ll feed my baby every 2 hours."

D. "I‟ll feed my baby every 2 hours."

A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply.)

A. Apply breast milk to the nipples before each feeding.

B. Place breast pads inside the nursing bra.

C. Massage the breasts and nipples prior to feeding.

D. Start breastfeeding with the nipple that is less sore.

E. Change the infant‟s position on the nipples.

A. Apply breast milk to the nipples before each feeding.

D. Start breastfeeding with the nipple that is less sore.

E. Change the infant‟s position on the nipples.

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

A. 22/min

B. 48/min

C. 100/min

D. 110/min

B. 48/min

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn‟s plan of care?

A. Monitor I&O.

B. Monitor axillary temperature.

C. Monitor blood glucose levels.

D. Monitor weight.

C. Monitor blood glucose levels.

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

A. Postpartum infection

B. Hypertension

C. Postpartum hemorrhage

D. Thromboembolic events

C. Postpartum hemorrhage

A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client‟s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

A. At the level of the umbilicus

B. 2 cm above the umbilicus

C. One fingerbreadth above the symphysis pubis

D. To the right of the umbilicus

A. At the level of the umbilicus

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimesterof pregnancy. Which of the following statements by a client indicates understanding of the teaching?

A. "These exercises help prevent constipation."

B. "These exercises help pelvic muscles to stretch during birth."

C. "They can help reduce back aches."

D. "They can prevent further stretch marks."

B. "These exercises help pelvic muscles to stretch during birth."

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

A. Variable decelerations are due to umbilical cord compression.

B. Variable decelerations are caused by uteroplacental insufficiency.

C. Variable decelerations are a result of the administration of IV narcotic analgesics.

D. Variable decelerations are related to fetal head compression.

A. Variable decelerations are due to umbilical cord compression.

A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch?

A. Babinski

B. Rooting

C. Moro

D. Stepping

B. Rooting

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn‟s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

A. "There is no need to worry about that. Most forms of hearing loss are not inherited."

B. "Look at how she looks as you when you speak. That‟s a good sign."

C. "We do routine hearing screenings on newborns. You‟ll know the results before you leave the hospital."

D. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles."

C. "We do routine hearing screenings on newborns. You‟ll know the results before you leave the hospital."

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Whichof the following responses should the nurse make?

A. Within 2 days

B. In 3 to 5 days

C. In 6 to 8 days

D. In about 10 days

B. In 3 to 5 days

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client‟s umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?

A. Cephalic

B. Transverse

C. Posterior

D. Frank breech

D. Frank breech

A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client‟s need to urinate?

A. Moderate lochia rubra

B. Fundus three fingerbreadths above the umbilicus

C. Moderate swelling of the labia

D. Blood pressure 130/84 mm Hg

B. Fundus three fingerbreadths above the umbilicus

A nurse is caring for a client who is breastfeeding her newborn and asks the nurse about the changes she should make in her diet. Which of the following dietary changes should the nurse suggest?

A. Increase her caloric intake by 600 kcal/day.

B. Increase her fluid intake to 2.5 L/day.

C. Reduce her intake of iron.

D. Avoid shellfish.

C. Reduce her intake of iron.

A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply.)

A. Fetal breathing

B. Fetal motion

C. Fetal neck translucency

D. Amniotic fluid volume

E. Fetal gender

A. Fetal breathing

B. Fetal motion

D. Amniotic fluid volume

A nurse is teaching a newborn‟s parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

A. Wash the cord daily with mild soap and water.

B. Cover the cord with the diaper.

C. Apply petroleum jelly to the cord stump.

D. Give a sponge bath until the cord stump falls off.

D. Give a sponge bath until the cord stump falls off.

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

A. 3 cm above the umbilicus

B. Slightly above the umbilicus

C. Slightly below the umbilicus

D. 3 cm below the umbilicus

B. Slightly above the umbilicus

A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following?

A. Ballottement

B. Lightening

C. Quickening

D. Chloasma

C. Quickening

A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn‟s chest circumference?

A. Sternal notch

B. Nipple line

C. Xiphoid process

D. Fifth intercostal space

B. Nipple line

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client‟s blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

A. Prepare for a cesarean birth.

B. Assist the client to an upright position.

C. Prepare for an immediate vaginal delivery.

D. Assist the client to turn onto her side.

D. Assist the client to turn onto her side.

A nurse in a provider‟s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

A. Cocaine use

B. Hypertension

C. Blunt force trauma

D. Cigarette smoking

B. Hypertension

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client‟s right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

A. Left lower

B. Right lower

C. Left upper

D. Right upper

D. Right upper

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?

A. Retained bile in the liver results in delayed digestion.

B. Increased estrogen production causes increased secretion of hydrochloric acid.

C. Pressure from the growing uterus displaces the stomach.

D. Increased progesterone production causes decreased motility of smooth muscle.

D. Increased progesterone production causes decreased motility of smooth muscle.

A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL system, which of the following describes the client‟s current status?

A. 4-0-1-2-2

B. 3-0-2-0-2

C. 2-0-0-2-0

D. 4-2-0-2-2

A. 4-0-1-2-2

A nurse is teaching about fetal development to a group of clients in the antenatal clinic. Which of the following statements should the nurse include in the teaching?

A. "The baby‟s heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy."

B. "The sex of the baby is determined by week 8 of pregnancy."

C. "Very fine hairs, called lanugo, cover your baby‟s entire body by week 36 of pregnancy."

D. "You will first feel your baby move in week 24 of pregnancy."

A. "The baby‟s heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy."

A nurse in a prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. Which of the following is the appropriate response by the nurse?

A. February 11, 2016

B. February 27, 2016

C. April 27, 2016

D. April 11, 2016

A. February 11, 2016

A nurse in a prenatal clinic is caring for a client who believes that she might be pregnant because she feels the baby moving. Which of the following statements should the nurse make?

A. "This is a presumptive sign of pregnancy."

B. "This is a probable sign of pregnancy."

C. "This is a possible sign of pregnancy."

D. "This is a positive sign of pregnancy."

A. "This is a presumptive sign of pregnancy."

A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?

A. Administer oxygen via nasal cannula.

B. Assist the client to breathe into a paper bag.

C. Have the client tuck her chin to her chest.

D. Instruct the client to increase her respiratory rate to more than 42 breaths per min.

B. Assist the client to breathe into a paper bag.

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?

A. Place the client in the lateral position.

B. Increase the rate of maintenance IV infusion.

C. Elevate the client's legs.

D. Administer oxygen using a nonrebreather mask.

A. Place the client in the lateral position.

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

A. Administer prescribed analgesic medication.

B. Encourage the client to rest between contractions.

C. Massage the client's back.

D. Turn the client onto her left side.

C. Massage the client's back.

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?

A. The presenting part is 1 cm above the ischial spines.

B. The presenting part is 1 cm below the ischial spines.

C. The cervix is 1 cm dilated.

D. The cervix is effaced 1 cm.

A. The presenting part is 1 cm above the ischial spines.

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

A. Fetal attitude is in general flexion.

B. Fetal lie is longitudinal.

C. Maternal pelvis is gynecoid.

D. Fetal position is persistent occiput posterior.

D. Fetal position is persistent occiput posterior.

A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

A. Observe color and consistency of fluid.

B. Assess the fetal heart rate pattern.

C. Assess the client's temperature.

D. Evaluate client for the presence of chills and increased uterine tenderness using palpation.

B. Assess the fetal heart rate pattern.

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider‟s orders. Which of the following orders requires clarification?

A. Assess deep tendon reflexes every hour.

B. Obtain a daily weight.

C. Continuous fetal monitoring

D. Ambulate twice daily.

D. Ambulate twice daily.